Monday, January 31, 2011

The Phalloclitoris: Anatomy and Ideology

This is a diagram of our shared heritage--yours and mine. It is a drawing of the genitalia we all start out with in the womb.

The Western medical establishment is deeply invested in the ideology of sexual dyadism: the idea that there are two very different sexes with two very different sets of genitalia. When children are born with genitals that are intermediate between the two, it is called a "malformation" and treated as bizarre and in need of immediate "correction." My earlier posts explain how this causes great suffering for intersex people. What I want to write about today is how the language we use and the diagrams doctors draw to illustrate genitalia hide the similarities between everyone's genitals. I believe that if we use more accurate language and diagrams, not only will we all understand eachother's bodies better, but the treatment of intersex individuals will improve.

Everyday Understandings of Genitalia

In the U.S., we live in a society that believes in two "opposite" sexes, men and women. Tell average Americans that sex is actually a spectrum of differences, and that there are societies which divide this spectrum into three or more sexes, and they'll just look at you funny. This is not because Americans are ignoramuses--it's just what we learned at home and were taught at school. Men have penises and testicles, children are told. Women have . . . well, women are presented as more complicated. Often children are told, "men have penises, women have vaginas." But then they learn at school (or in schoolyard talk) that the vagina is "the hole where a penis can go," but there are more parts to the female anatomy, and the most sensitive bit is the clitoris. By high school biology class most of us have dutifully learned that the technical term for the female genitalia is the vulva, made up of not only clitoris and vagina but labia minora and majora, the inner and outer lips, and that inside women have ovaries and uteri. What we are taught about male anatomy remains simple: men have a penis and testes. From this anatomical distinction we are taught to understand people as falling into two camps: straightforward, goal-oriented, insensitive men and complicated, vulnerable, sensitive women. That's gender dyadism, American style--the fodder for endless TV sitcoms.

What we are not usually taught is that that all humans start out in the womb with the same initial genital structure. This is certainly studied by embryologists, if not familiar to the general public, and I will give a basic tour in this post. I'm not going to use the language embryologists do, though, because I find it very odd. They refer to the initial human form as the "indifferent stage," often say that the genitals "appear female," yet term the sensitive end of the genital structure the "phallus." The truth is that we all start out appearing neither female nor male, and we certainly don't start out with penises. We all start out intersex. Our initial form (which some of us retain) is pictured at the top of this post. Let's examine it.Human Genital DevelopmentWe all begin life with genitals that have four basic external elements. At the top is the part numbered 1 on my drawing: the sensitive end of the phalloclitoris, which can differentiate into the head of the penis or clitoris. In the center is structure 2: an inset membrane that can widen or can seal as the fetus develops. It will form the urethra, and the vagina, if any. Around it is structure 3, which is capable of differentiation into either a phallic shaft, or clitoral body and labia minora. And at the outside is the fourth part, the labioscrotal swellings, which can develop into labia majora or a scrotum.

There is a lot of variation in how each of the four basic parts of the genitalia develop from person to person in all of us. For example, we acknowledge with a lot of rib-elbowing the variation in penile size. Variation in the size and shape of genitalia, and in other parts of the body, is part of human diversity. Surgeons are well aware that livers and lungs and blood vessels vary a lot between individuals, and may look quite different from an iconic anatomical diagram. But we rarely care about having an unusually shaped liver. The shape of genitals, however, is given huge cultural weight, because we pin our commitment to dyadic gender roles on them. We look at the shape of a newborn's genitalia and project a future of dresses and diets and talking about emotions, or sports and strength and getting under the hood of a car. We do know that people are complicated. Most of us want to be more than walking gender stereotypes. Still, we understand people through the lens of dyadic gender difference, and intersex people call that into question. When we see a baby born with intermediate genitalia, and can't project a future for them based on our well-known gender narratives, people in our society--including doctors--freak out.

Part of the reason our culture reacts so poorly to intersex people is that doctors have spent the past 75 years or so erasing the bodies of people like me. I'm referring not only to the fact that doctors surgically alter our genitals, nor only to the fact that we're given an "M" or an "F" on our birth certificates, but to the fact that anatomical illustrations don't illustrate our anatomies. Medical drawings and medical language obscure our existence. And since I want doctors and parents and society at large to stop freaking out and erasing us, I want that to change.

Anatomical Illustrations of Adult GenitaliaVariation in the shape of genitalia is a fact of nature. Some genital variations are labeled intersex conditions by doctors, and considered unacceptable malformations that must be "corrected." Other variations doctors insist with equal vehemence not to "really" be intersex. There is little logic to this if you look at it from the perspective of physical health or function. Instead what seems to matter are ideologies: first, an insistence that all people must be "really" male or female; and second, an anxious commitment to associating men with big penises. And this is visible when you examine anatomical drawings.

Let's look at how doctors portray adult genitalia. Anatomy drawings in Western medicine present two and only two types of "normal" genitals. I don't have permission to post copyrighted medical illustrations, but a sample female genital diagram can be see here, and an example of a male genital diagram here. These drawings of dyadic sexual anatomy could be critiqued in many ways, but for now let's consider just one thing: the way the phalloclitoris is portrayed. In the female drawing, it's presented as a tiny clitoral dot, with the label pointing at a spot the size of a small pea. In the male drawing, it's presented as a huge penis, shown in the illustration I've linked as extending beyond the testes, apparently 8 inches or more in length even in its flaccid state. To put it plainly, the "normal penis" in this medical drawing is porn-star sized rather than average, and massive in comparison to the petite "normal clitoris."

Not only do these medical illustrations exaggerate sexual differentiation, they obscure rather than illuminate shared anatomy. Note that only the tip of phalloclitoral structure protruding from the foreskin or "hood" is labeled "clitoris." In fact, the phalloclitoris is similar in size between people at all points on the sex spectrum. In people with genitals that conform closely to the male end of the sex spectrum, the structure I've labeled #3 above merges into one erectile column. "Men" get a "penile shaft." In people with genitals that conform closely to the female norm, the two sides of the structure spread apart and surround the labia majora. "Women" get . . . well, what do you call that? Anatomists call these two feminized sides of the phalloclitoris the "clitoral crura," a term that most laypeople have never learned at school. Just like the penile shaft they are made of several inches of spongy tissue that fills with blood and erects during sexual excitement. You can see an anatomical illustration here (look at the part labeled "crus clitoris," the singular of "crura" in Latin). As you can see, the phalloclitoris is actually quite similar in men and women. The tip bends down in women and the two sides are joined together in men, but the basic structure is the same.

You would imagine that anatomical drawings would illustrate all of our genital structures to increase understanding. But do a Google image search for "female genital anatomy" and you'll see hundreds of images that look like this--and just one image in the first 10 pages that shows the crura. The anatomical illustrations that are used on educational and medical websites conceal rather than illuminate the similarities in everyone's phalloclitoral anatomy.

Do a Google search for just "genital anatomy" and you see dyadic illustrations of two very different types of genitalia. You don't see the shared embryonic anatomy from which we all develop, you don't see how all people have similar phalloclitoral structures as adults, and you don't see the wide spectrum of adult genital forms that exist. You see the ideology of sex dyadism, rather than the fact of the sex spectrum.

The Moral of the Anatomical Fable

In my next post I will discuss the common variations on the human genital theme, and why some and not others are called intersex conditions by doctors. What I want to conclude with today is the fact that language and the images scientists and doctors use exaggerate the differences between "normal" male and female genitalia. In a culture where people believe genitals determine gender, this makes men and women seem in general more different, more alien from one another, harming us all. And for intersex people, anatomical drawings and language present us as bizarre, inexplicable freaks who require medical "correction."

We need to change the language we use. Yes, sexual differentiation of bodies happens. The average person who was assigned male at birth has smaller nipples than the average person who was assigned female at birth. But we call the erectile tip of the areola a "nipple" whatever the sex of the person it adorns. A phalloclitoris is a phalloclitoris, erectile and sensitive--no matter if the person possessing it is deemed male, female, or intersex. In simple terms, some of us are more "outies" and some are more "innies" and some right in between--but we all share the same genital structures. You have a phalloclitoris, and so do I. We are all variations on the same bodily theme, and there is no need to react to intersex bodies with pity or horror.

16 comments:

Awesome post, I think people would understand all sorts of gender/sex issues better if they knew more about fetal development. As a trans man (though I'm not intersex), it does help me to feel better about my own anatomy when I realize how similar all of our genitals really are. Rather than - as you said - the absolute misinformation society feeds us about "female" and "male" genitals being unrelated opposites.

It's really true how exaggerated both the "female" and "male" diagrams are, that never quite hit me before, even if I've complained about them in other ways. I wish people could see both physical sex and gender as the spectrums they are.

Anyway, I'll definitely be directing people to this post if I wanna explain genital development to them. Your blog is really informative for me, too. Looking forward to more posts in this series.

I made a group for intersex survivors of abuse, because I can't find anything that's out there for us. This is a gross problem, so here is my page. If you're interested in helping, please pass it around, or offer some other help through the page. Thanks.

Very informative. It's weird how you can live an entire life without knowing about a body part you have. Everybody should know about this, but unfortunatly I believe most people don't want to know. If anyone told them, they would probably put their fingers in their ears and go: "lalalala, I can't hear you!"Anyway, keep up the good work. People have to be educated, even the ones that don't wanna :)

I think what most intersex people need is a list of doctors and lawyers in major cities who are willing to represent them there.

after they realize what all the family snickering is about and they figure out that mom and dad had the doctor slice them up "for the family's sake"

sort of an "honor" thing I guess

seems to be a lot of that.

I've literally had 5 different general practitioners laugh or try to tell me I was "delusional" and had a "mythological condition".

Therapeutic Privilege is the norm, and if you talk about it too much or demand a specialist you get nothing

I have to say I was shockedwhen a transgender nurse with $100,000 in surgery hormones and psych behind hertells me there are no specialists for intersex adults, you accept the designation of the health authority or you are labelled trans here

I think you would be one of the few people who would understand that I get offended when I am called trans by a health "professional" as intersexuality is genetic-biological-developmental and trans is psychological.

This is in Vancouver Canada I'm writing from!

Maybe you can find something of interest here in your off time, my blog is christuusgnosis.wordpress.com

Thank you, thank you, thank you for writing this! I have always been one to advocate for gender as being very much of a spectrum, even though I identify and am anatomically female. For some reason I have always been interested in this area of the medical field, despite being ridiculed, told I was "wrong" when pointing out the gender spectrum, and even when other people have questioned my sexual orientation as a result of my interest in this area (what the hell does sexual orientation have to do with the gender spectrum, anyway?).

I wish more people could see your blogs, Cary, especially those in the nursing field!

educational, knowing us I am unsure how to response. We play mean game and I am not sure we want to change. There are so many things we buy into then act as if we are moral, ethical. In my world very few individuals as gotten beyond the Homo sapiens stage and know nothing of making choices as human. I can only promise to fight the good fight. Therefore I hope you understand and accept what we are dealing with.

This opinion piece is selling human rights apartheid! - denying some children basic human rights based simply on a doctors diagnosis! The right for children to grow up to discover their own identity and sexuality and not have their sexual or personal development foreclosed by interference from adults (or from irreversible decisions being asked of them before sexual maturity) has been a central battle not just for intersex activists but also for activists fighting FGM, child marriage and child sexual abuse. While many children would nominally "agree " to FGM, or to Child Marriage we do not accept such agreement as informed consent . Because the child is not mature, and their agreement is about fitting into the small world their parents and immediate community define for them not about their own desire or independent direction. We defend the right of all children (or we should) to grow and make choices, in the wider world, not maimed or limited by their upbringing. And decisions about sex , or anything that might impinge on sexual future should be made by sexually mature sexual agents and not asked of pre-adolescents. .....cont...I'm a a pro-diversity, intersex activist and trans ally and i'd appreciate an opportunity to submit my full reply to this! Georgina

It is sometime since this piece was written. I think as time goes by more and more readers will discard their prejudices in the face of the facts. Congratulations on an important and well written piece

It is sometime since this piece was written. I think as time goes by more and more readers will discard their prejudices in the face of the facts. Congratulations on an important and well written piece

It is sometime since this piece was written. I think as time goes by more and more readers will discard their prejudices in the face of the facts. Congratulations on an important and well written piece

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About Me

I'm an academic and scaler of boundary walls, intersex by birth, female-reared, legally transitioned to male status, and pleased with my trajectory. Come journey with me! I blog about intersex issues at http://intersexroadshow.blogspot.com/, and about trans issues at http://trans-fusion.blogspot.com/.
If you are interested in contacting me or having me speak to your organization, please email intersexroadshow@gmail.com.